Your body, your choice

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The transforming experience of childbirth is increasingly blotted by medical interventions. Are women making informed decisions?

LIKE most first-time mothers, Faye Wong ... was incredibly excited when she got pregnant. She read baby books and magazines voraciously, signed up for ante-natal class ... to prepare for baby's arrival.

When she was 38 weeks pregnant, her obstetrician said the baby's head had engaged and his size was quite big. The doctor suggested inducing her labour.

In the labour room, her "nightmare" began. The pain from the drug-induced contractions was a rude jolt to her system. Then she was jabbed and prodded with painkillers, IV tubes and the works.

"I was shocked, confused, and in absolute terror," recalls Wong, 35. Finally, the induction failed and she had to be wheeled in for emergency caesarean. Thankfully, she delivered a healthy baby boy weighing 3.9kg. When she got home, she struggled with breastfeeding and suffered a severe bout of post-natal blues.

"I felt ‘cheated' ... " Wong admits. Her son is now seven. "I was a newbie to the birthing process and was meek as a lamb led to the slaughter," she adds. "If I'd known then what I know now, I probably would have been better prepared, stood my ground and not undergone early inducement." Though doctors play a role in giving women the necessary information about labour options, women and their partners need to take their share of responsibility too in making informed choices and decisions.

Wong's experience isn't unique.

"We see a fair amount of women who are unhappy about the outcome of their deliveries," says Jennifer Hor of Jenlia Maternal Services. The UK-trained midwife has been running ante-natal classes and post-natal home visits for 17 years. "Some felt they had a C-section even though they didn't want it. Or, some felt they didn't get enough information from their doctors."

So, are women less assertive when it comes to childbirth? Are they getting or finding the information necessary to make informed choices and decisions? And have we forgotten that childbirth, an age-old practice, is meant to be natural?

Birth trends

... the medicalisation of childbirth means what used to be a straightforward, natural process is now treated as a high-tech medical procedure.

Caesarean rates are on the rise in both developed and developing countries ...

... "Women say they want to take ownership of their bodies, yet we have healthy, low-risk women who said they had a C-section for their first births because they listened to their doctors," says Farouk, who also sub-specialises in reproductive medicine. And because of the risks from the first surgery, these women are requesting for repeat C-sections. "Ironically, women are pushing the trends that way.

"We are also seeing the use of more technology to manage pregnant mothers, for example using CTG (cardiotocography) ... and ultrasound scans," says Farouk. "It's not all bad, but if you monitor too much, you might pick up something and wonder if you don't take action, there might be consequences, hence the interventions."

... Doctors come with their beliefs and agendas, based on experiences. Some underplay certain risks and amplify others. For instance, placental calcification ... is not a major issue for some obstetricians if the woman is near term and foetal growth is normal. But for a different doctor, a few specks on the ultrasound scan is reason enough for labour induction.

"There can be grey areas in medical investigations. I tend to be more conservative with placental calcification and continue to monitor foetal health and growth parameters," ...

Also, fear of litigation is scaring obstetricians into defensive and often interventionist practices.

"An obstetrician is more likely to be subjected to litigation because a caesarean section was not performed or was perceived to have been performed too late ..."

Medical interventions

Clearly, it's not always true that C-sections or epidural blocks are being foisted on reluctant women. The fact is, some women don't question their doctors, or they themselves are asking for interventions.

Labour induction, elective caesarean, epidural jabs, and routine episiotomy are some of the common medical interventions during childbirth.

Induction of labour ... is usually done when the mother's or baby's health is at risk ...

"For such cases, studies have shown that caesarean section rate has been unchanged or lower among the induced group as compared with expectant management of pregnancy ... "

"But induction of labour at 37 to 41 weeks on non-medical grounds is linked with an increased risk of caesarean section for ... a woman who has never given birth and an increased risk of instrumental delivery," ...

No doubt, medical interventions can be a lifesaver for mothers and babies ...

However, once the natural process of labour and birth has been disturbed, if there is no actual emergency, there is risk that the side effects of the treatment will trigger more intervention necessary to fix the problem. This sequence of events is called the "cascade of interventions".

"Pitocin (Syntocinon), a synthetic form of the hormone oxytocin used to induce or speed up labour, often results in a rapid increase in the intensity and strength of the woman's contractions. As a result, she may opt to use pain medications such as pethidine ... or epidural anaesthetic. Babies sometimes don't react favourably to the sudden increase in the intensity of the contractions, which may result in irregularities of the heartbeat. Thus in turn may necessitate delivery by caesarean," ...

"Many women who use epidural do not experience the urges to bear down which help them to birth their babies. Often, in this situation, the doctor will use forceps or vacuum to deliver the baby, which means he needs to do an episiotomy ... Many women experience long-term perineal pain following episiotomy."

A failed induction (when labour doesn't started after the first cycle of treatment) can either require a rescheduled induction or emergency C-section.

"Women should received accurate information about the risks, benefits, and alternatives of induced labour and understand the possible side effects and interventions, " ...

The big ‘C'

Most women also come with the preconceived idea that C-sections are safer than vaginal delivery ...

... "In fact, C-section, which is classed as a major surgical procedure, carries with it the risk of complications and shouldn't be viewed as an alternative option to normal birth."

... "Babies delivered by elective caesarean section at 37 to 39 weeks' of pregnancy are at two to four times more likely to suffer from respiratory morbidity compared with babies delivered by vaginal delivery," ... WHO global maternal survey also finds that women who choose elective caesarean with no medical indication are at increased risk of maternal death and serious complications.

... Studies have linked depression and distress after birth, which affect up to one in five women, to forceps and caesarean births ...

Disturbed birth

"You must be mad to give birth without an epidural!" A common reaction these days if you speak with women who have undergone labour. But as the WHO states, "epidural analgesia is one of the most striking examples of the medicalisation of normal birth, transforming a physiological event into a medical procedure."

... in her book,Gentle birth, gentle mothering, internationally acclaimed birth expert Dr Sarah J. Buckley explains how epidurals or painkilling drugs and synthetic hormones (used during induction) interfere with some of the major hormones of labour and birth. The five major hormones: oxytocin (hormones of love); beta-endorphin (pleasure and transcendence); the catecholamines or CAs, epinephrine and norepinephrine (excitement); and prolactin (tender mothering) form a "cocktail of hormones that nature prescribes to aid birthing mothers of all mammalian species".

During an undisturbed labour, these hormones rise in crescendo and peak around the time of birth or soon after for mother and baby, and subside over the following hours and days. "An optimal hormonal orchestration provides ease, pleasure, and safety during this time for mother and baby." Interference with this process, by injecting drugs or synthetic hormones, will "disrupt the hormonal orchestration, making birth more difficult and painful, and potentially less safe".

For example, epidurals lower the mother's production of oxytocin or stop its normal rise during labour. Oxytocin causes a woman's uterus to contract in labour. It peaks at birth and catalyses for the final powerful contractions of labour, and helps mother and baby to fall in love at first meeting.

Under stressful conditions, our body releases epinephrine and norepinephrine (CAs). Towards the end of an undisturbed labour, the mother experiences an adrenaline rush – the natural surge in these hormones gives her the energy to push her baby out, makes her excited and fully alert at first meeting with her baby.

But when a woman feels fearful or unsafe, her labour is inhibited by high CA levels. Epidurals reduce the release of the CAs, which may be helpful if the high levels are restricting her labour. However, a reduction in the final CA surge may make it difficult for the woman to push her baby out, thus increasing the risk of instrumental delivery (forceps and vacuum).

Epidural's side effects include nausea, slowing of labour and drop in blood pressure, slowing of contractions, and headache.

35-year-old Laila Aziz of Kuala Lumpur was wheelchair-bound for four months after an epidural jab injured her nerves when she delivered her third child.

"I wish my O&G and the anaesthetist had explained in details the pros and cons of using an epidural," says Laila, who suffered severe post-natal blues after childbirth. "I would at least reconsider whether to use the option at that time."

... Childbirth educator and lactation consultant Christine Choong has been advocating natural childbirth for the past two decades.

"My main passion is how birthing practices affect breastfeeding. What happens when you're in labour can have a long-term effect on your breastfeeding," ...

Research has shown that when you put a baby on his mother's chest (skin-to-skin contact) immediately after he was born, the baby will crawl instinctively towards her breast.

"Quite often the baby won't do that if you had used drugs during labour ... because he will be drowsy the first two to three days," ... "If women use epidural, very often their babies are delivered by suction or forceps which can cause discomfort on baby's head (a shock to the system) and baby initially will not be happy feeding on one side or the other."

Whether a labour induction is done on medical grounds or not, the baby is – by definition – relatively immature and likely to have impaired ability to effectively coordinate sucking, swallowing, and breathing at breast ...

"In a C-section delivery, very rarely the mother is given the baby straight away," Christine adds. "Early stimulation or suckling is important to establish breastfeeding. Also a higher percentage of caesarean babies end up with respiratory problems, which results in separation of mom and baby."

But we need to look at the whole picture – the impact on baby, feeding, and mother-baby relationship.

"It isn't just feeding but also nurturing," says Christine, a mother of three.

"When babies are nurtured and their needs are met, in the long term, they will become people who are secure, confident, and know how to form relationships with people."

Take control

What do you do if your care provider says you or your baby is at risk and an intervention is necessary?

"Using evidence-based information, your doctor should explain the reason for any suggested interventions. He should also explain the benefits and risks of such procedures," advises Choong. If you're not sure or not too convinced by your doctor's explanation, get a second opinion."

"Empowerment with the correct knowledge and information is useful so women can ask the correct questions," Chow adds. "And their fear of childbirth should be addressed by getting support and learning about the labour process and pain relief options."

Ultimately, a woman's satisfaction with her birth experience is related more to her involvement in decision-making than to the outcome, as Buckley emphasises. Though doctors play a role in giving women the necessary information, women and their partners need to take their share of responsibility too in making informed choices and decisions.

When Wong had her second child, she was more mentally and emotionally prepared.

"Although I ended up having another C-section (due to hypertension), I didn't feel disappointed and helpless," Wong says. "I felt as if I was a real mom this time around."

As Buckley sums it up best, "birth is the beginning of life; the beginning of mothering and of fathering. We all deserve a good beginning."

Melissa Maimann, Essential Birth Consulting 0400 418 448